Acute HF Patients Live Longer When Seen by Specialists

Patients admitted to the hospital for acute heart failure (HF) are much more likely to be discharged on guideline-directed medical therapy (GDMT) and receive specialized follow-up care if they are seen by HF specialists during the initial admission, according to a new study.

Being seen by specialists was also associated with better long-term survival, a benefit that was particularly pronounced in patients who had heart failure with reduced ejection fraction (HFrEF).

“If you see patients with heart failure within their hospitalization, there is a long-lasting benefit because if you start early [with GDMT], the therapeutic intervention will change their life,” lead investigator Antonio Cannata, MD (King’s College London, England), told TCTMD. “We are spoiled in cardiology because we have very good results from clinical trials. The magnitude of [benefit] with what we're doing is in terms of the decades, rather than just adding 1 or 2 more years of life.”

In the United Kingdom, the National Institute for Health and Care Excellence recommends that all patients with acute HF be seen by an HF specialist, either a doctor or physician with a clinical interest in HF and/or a specialist nurse. Even so,  it can be challenging to see all admitted patients during the hospitalization, Cannata said, adding that there’s a need for more specialized providers, both in the United Kingdom and around the globe.

Prior studies have demonstrated that in-hospital HF specialist care can result in better uptake of GDMT in HFrEF patients, and these treatments have been shown to significantly improve long-term survival. Less is known about the role of specialized care in patients who have heart failure with preserved ejection fraction (HFpEF), a population in whom the evidence for GDMT is weaker.

“Looking from a health economics point of view, we need to identify the people that definitely need more specialized follow-up,” Cannata said. “It’s one of the reasons why we did this analysis, to understand the benefit across the entire spectrum of left ventricular ejection fraction. We know that specifically for patients who have a preserved ejection fraction, the strength of the evidence is quite low compared to those with heart failure and reduced ejection fraction.”

The study was published online this week in JACC: Heart Failure.

Longer Stay but Fewer Diuretics on Discharge

The analysis, derived from three national datasets spanning from 2018 to 2022, including the National Heart Failure Audit for England and Wales, was based on 227,170 patients (median age 81 years) with HF, of whom 53% were admitted with HFrEF. The majority of patients were severely symptomatic, with 167,760 in NYHA functional class III/IV and more than half admitted with moderate-to-severe peripheral edema.  

Overall, 80% of admitted patients received care either from an HF specialist or by a noncardiology physician with a clinical interest in HF and/or HF specialist nurses. Slightly less than 40% were seen by a multidisciplinary team with HF physicians and nurses, 22% were seen by HF specialist nurses alone, and the rest seen by HF doctors alone. Those receiving specialist care were younger (80 vs 85 years) and more likely to be male and to have HFrEF. Nearly 90% of HFrEF patients were seen by HF specialists while only 72% of those with “non-HFrEF” received specialized care. 

Length of stay was longer for patients seen by HF specialists—8 versus 4 days for those not seen by HF experts—but those with HFrEF seen by specialists were more likely to be prescribed GDMT. For example, 74% of HFrEF patients were prescribed a renin-angiotensin-system (RAS) inhibitor or angiotensin receptor-neprilysin inhibitor (ARNI) versus 56% not seen by HF specialists (P < 0.001). Additionally, 86% were prescribed a beta-blocker and 56% were prescribed a mineralocorticoid receptor antagonist (MRA), rates that were significantly higher than those not seen by HF specialists (74% and 33%, respectively; P < 0.001). 

Loop diuretics, on the other hand, were less likely to be prescribed by HF specialists than by nonspecialists. Specialized follow-up care—either with a cardiologist or HF specialist nurse—was also more likely if patients were seen in the hospital by HF experts. 

After adjusting for patient demographics, signs and symptoms of HF, discharge medications, and disease severity at presentation, being treated by an HF specialist in the hospital was associated with a lower risk of all-cause mortality (HR 0.89; 95% CI 0.87-0.90) over 56 weeks. The benefit was stronger in those with HFrEF (HR 0.85; 95% CI 0.83-0.86) than in those without HFrEF (HR 0.91; 95% CI 0.89-0.93).

Importance of Multidisciplinary Care

In-hospital treatment by a multidisciplinary team was significantly associated with the best survival. For those who survived to discharge, specialized follow-up, either with an HF nurse or cardiologist, was associated with better long-term survival. 

“If you see both heart failure doctors and nurses, then the outcome is much better,” said Cannata. “When you think about the role that each one of the healthcare professionals have, the doctors are responsible for the more complex pathway of both diagnosis and treatment while the nurses, especially in hospital, are more focused on education and perhaps helping with the uptitration of medication. During that index hospitalization, their role is a little bit more limited.”

Outside the acute admission, specialized nurses have a larger role, he added. They can see patients more frequently and identify red flags that may signal potential rehospitalization risks.

Regarding the increased length of stay, Cannata said one potential explanation is that observation takes a little longer to ensure patients are started on GDMT. The longer hospitalization also parallels the lower use of loop diuretics in patients seen by HF specialists. Being less likely to be discharged on diuretics might be the result of better decongestion in the hospital, which would contribute to the increased length of stay.  

“If you properly treat patients, sometimes it may take a little bit longer, but it can improve prognosis and reduce the requirement for other type of medications,” he explained.

The present study focused on triple treatment with RAS inhibitors/ARNIs, beta-blockers, and MRAs, but sodium-glucose cotransporter 2 (SGLT2) inhibitors have since been recommended as part of the cornerstone of HF therapy irrespective of LVEF.